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Frailty is associated with worse outcomes in acute coronary syndromes: outcomes in TRILOGY

Session Rapid Fire - Antiplatelet therapies in acute coronary syndromes

Speaker Harvey White

Event : ESC Congress 2013

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Acute Coronary Syndromes: Antiplatelet Agents
  • Session type : Rapid Fire Abstracts

Authors : H D White (Auckland,NZ), M Roe (Durham, NC,US), K Alexander (Durham, NC,US), C Westerhout (Edmonton, Alberta,CA), K Winters (Indianapolis, IN,US), K Fox (Edinburgh,GB), D Prabhakaran (New Delhi,IN), J Hochman (New York, NY,US), P Armstrong (Edmonton, Alberta,CA), E M Ohman (Durham, NC,US)

Authors:
H.D. White1 , M. Roe2 , K. Alexander2 , C. Westerhout3 , K. Winters4 , K. Fox5 , D. Prabhakaran6 , J. Hochman7 , P. Armstrong3 , E.M. Ohman2 , 1Auckland City Hospital - Auckland - New Zealand , 2Duke Clinical Research Institute - Durham, NC - United States of America , 3Canadian VIGOUR Centre, University of Alberta - Edmonton, Alberta - Canada , 4Eli Lilly and Company - Indianapolis, IN - United States of America , 5University of Edinburgh, Centre for Cardiovascular Science - Edinburgh - United Kingdom , 6Centre for Chronic Disease Control - New Delhi - India , 7New York University Langone Medical Center - New York, NY - United States of America ,

Citation:
European Heart Journal ( 2013 ) 34 ( Abstract Supplement ), 826

Purpose: Little is known about frailty in ACS patients and there is no information about the safety and efficacy of P2Y12 antagonists in this setting. We therefore assessed the impact of frailty in ACS patients enrolled in TRILOGY.

Methods: TRILOGY randomized 9326 patients with unstable angina or NSTEMI who were planned for medical management without revascularization to receive prasugrel (10 mg/d; 5 mg/d for patients ≥75 y or <60 kg) or clopidogrel 75 mg/d. The primary endpoint was a composite of cardiovascular death, MI, or stroke. The Fried Frailty Score was administered to 4699 (99.9%) patients >65 y. Score items included weight loss, exhaustion, physical activity, walk time, and grip strength. Association of frailty with the primary endpoint was adjusted for GRACE Risk Score covariates; HRs and 95% CIs are presented.

Results: 72.3% of patients were classed as not frail, 23.0% as pre-frail (1-2 items), and 5.1% as frail (≥3 items). Increasing frailty scores were associated with most risk factors and with increasing age: 0 items, 73.0 y; 1-2 items, 74.0 y; ≥3 items, 75.0 y; female sex (46.0%, 45.9%, and 50.2%); and higher GRACE scores (134.0, 138.0, and 144.0), respectively. Ischemic outcomes and bleeding are shown in the table. Frailty was significantly associated with the primary endpoint (pre-frail vs not frail: adjusted HR 1.33 [95% CI 1.11-1.60]; frail vs not frail: 1.55 [1.12-2.13], p<0.001).

Conclusions: Frailty is strongly associated with the composite of cardiovascular death, MI, or stroke as well as all-cause mortality. No association of frailty with bleeding was observed in the TRILOGY trial.

Table 1. Ischemic and bleeding outcomes
Endpoint; Kaplan-Meier estimates at 30 monthsNot frail (n=3612)Pre-frail (n=1147)Frail (n=237)P, Frail vs Not Frail
Cardiovascular death /MI/stroke composite23.1% (21.1–25.2)29.2% (25.6–32.9)39.7% (29.5–50.0)<0.001
Cardiovascular death12.8% (11.1–14.5)17.8% (14.7–20.8)26.6% (16.7–36.5)<0.001
MI12.8% (11.3–14.2)16.8% (13.7–20.0)18.9% (11.3–26.5)0.001
Stroke3.2% (2.0–4.4)3.6% (2.3–5.0)4.9% (0.0–10.0)0.043
All-cause death15.0% (13.4–16.7)21.7% (18.5–24.9)30.2% (20.8–39.6)<0.001
GUSTO severe/life-threatening2.0% (1.0–3.1)1.2% (0.3–2.2)0.6% (0.0–1.80)0.791
GUSTO severe/life-threatening/mod5.0% (3.5, 6.4)3.7% (1.9–5.5)4.2% (0.0–8.7)0.928
TIMI major bleeding3.1% (2.0–4.2)2.4% (0.6–4.1)1.1% (0.0–2.6)0.299
TIMI major/minor4.7% (3.3–6.0)4.7% (2.4–7.1)5.9% (0.0–11.9)0.934

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